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Images in Women's Health

July 2003

Leeber Cohen MD; Lisa Mazzullo MD

Case

The patient is a 38-year-old P2 with a history of left salpingo-oophorectomy for a borderline serous cystadenoma in her early 30s. The patient was followed with annual pelvic examinations and pelvic ultrasounds. On bimanual examination, a 6-cm mass was identified in her right adnexa and confirmed by ultrasound. Ultrasound revealed a 6-cm multilocular-solid cyst by International Ovarian Tumor Analysis classification¹ measuring 6.9 x 5.3 cm. (Figure 1). Power Doppler revealed a 1.5 x 1.0-cm excrescence with vascular flow. Velocimetry revealed a resistance index (RI) of 0.52 (Figure 2).

Click to enlarge

Figure 1.

Findings

At laparotomy, the patient was found to have a stage I borderline tumor. Transabdominal hysterectomy with left salpingo-oophorectomy was performed since preservation of reproductive function was not desired. Staging was consistent with a stage I borderline serous tumor.

Discussion

The echo features of borderline tumors have been reviewed by Gott lieb et al.² Approximately 13% of the masses in their series were simple cysts. Seventy percent of the mucinous tumors and 37% of the serous tumors, respectively, were greater than 8 cm. Solid components or papillations (excrescences), as in this case, were seen in 65%.

An RI of less than 0.4 was only seen in 45% of the cases. The history of a previous borderline tumor, the presence of a solid excrescence within one of the cystic locules, and vascular flow within the solid element, made recurrent borderline tumor very high on the differential. The presence of central vascular flow within a solid element of a tumor has been shown to be correlated with a high risk for malignancy in patients with frank ovarian cancer.^3,4 Unfortunately, in our experience, only about half of borderline tumors display central vascular flow within a solid element of the tumor (unpublished data). Color or Power Doppler appears useful in mapping vascular flow within tumors. The role of actual velocimetry measurements in borderline cases is questionable.

Leeber Cohen, MD, is a private practitioner and on the volunteer faculty at Northwestern University Medical School, Department of Obstetrics and Gynecology; and Lisa, Mazzullo MD, is assistant clinical professor, Northwestern University Medical School, Department of Obstetrics and Gynecology, both in Chicago, Ill.

References

1. Timmerman D, Valentin L, Bourne TH, Collins WP, Verrelst H, Vergote I; International Ovarian Tumor Analysis (IOTA) Group. Terms, definitions, and measurements to describe the sonographic features of adnexal tumors: a consensus opinion from the International Ovarian Tumor Analysis (IOTA) group. Ultrasound Obstet Gynecol. 2000;16(5):500-505.
2. Gotlieb WH, Soriano D, Achiron R, et al. CA 125 measurement and ultrasonography in borderline tumors of the ovary. Am J Obstet Gynecol. 2000;183(3):541-546.
3. Schelling M, Braun M, Kuhn W, et al. Combined transvaginal B-mode and color Doppler sonography for differential diagnosis of ovarian tumors: results of a multivariate logistic regression analysis. Gynecol Oncol. 2000; 77(1):78-86.
4. Timmerman D, Bourne TH, Tailor A, et al. A comparison of methods for preoperative discrimination between malignant and benign masses. The development of a new logistic regression model. Am J Obstet Gynecol. 1999;181(1):57-65.

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